Analysis Vessel Activity Although a well-established marine transportation system exists to facilitate the summer resupply of Canada's northern territories, the system's complex scheduling is not always flexible enough to provide for the short-term needs of northern communities. As a result, a demand has developed for smaller vessels such as the Avataq that can operate on a more flexible schedule. Economically, it is more advantageous for a northern vessel operator to purchase an existing vessel in southern Canada than to construct a purpose-built vessel. Therefore, small fishing vessels such as the Avataq, which may be unsuitable to carry cargo, have become commonplace in the North. TCMS does not maintain a resident surveyor in the Port of Churchill, nor would it be reasonable to expect it to do so. The Canada Shipping Act, however, does provide a statutory mechanism for the inspection of any vessel by a port warden or other competent person. In a small port such as Churchill, with relatively few ship movements, the identification of vessels loading cargo in an unsafe manner is not difficult, particularly if a trained and competent port warden is already present and directed to act as the eyes and the ears of TCMS. There was an awareness that the Avataq and other similar fishing vessels were engaged in the loading of cargo at the Port of Churchill for delivery to communities on the western shore of Hudson Bay since the vessel began operating out of Rankin Inlet in 1995. During this time, concerns for the safety of the vessel's loading practices had not been identified and passed on to the appropriate authorities. As a result, no assessment was made to determine whether the vessel's cargo was properly loaded or if it was seaworthy as a cargo vessel.(11) Cargo vessels are required to have load-line markings and to have a stability book to assist the master in safely loading the vessel. Foundering Following Inuit seafaring (Quajimajatuqangit),(12) the Inuit of the western shore of Hudson Bay traditionally followed a route close inshore between Churchill and Arviat, anchoring each night. Modern electronic aids to navigation have given vessel operators the tools to confidently take a more direct route offshore, generally following the 94th meridian towards destinations along the western shore of Hudson Bay. Consequently, vessels such as the Avataq, when following this offshore route, are more likely to be caught offshore by unexpected severe weather conditions. Little is known of the stability characteristics of the Avataq when heavily loaded, with little residual freeboard. The design to which the Avataq was built is such that the space below deck was subdivided into a number of small compartments by transverse bulkheads. As a result, the Avataq carried most of its bulky, heavy cargo lashed on the deck. As demonstrated on a previous voyage during which the vessel nearly capsized, when loaded with 15 823 kg of cargo in this manner, the vessel's centre of gravity would have risen to a point where the vessel had little margin of stability. When fully loaded, the vessel's freeboard was 40 cm. The scuppers were therefore below the waterline, and barrel plugs had been screwed into them to prevent water from flooding the afterdeck. Although this arrangement prevented water from backflooding the afterdeck, it also caused the vessel to retain any water shipped on deck. When the Avataq encountered heavy seas south of Arviat, it began to ship water on the afterdeck. Without watertight hatches, some of the shipped water would have downflooded into the hull; however, most would have been retained on the afterdeck.Whenever water is shipped and retained on deck, a free surface effect effectively reduces stability by causing a rise in the virtual centre of gravity. The free surface effect of the shipped water retained on the afterdeck probably reduced the vessel's already marginal transverse stability characteristics, causing the Avataq to heel, downflood, and sink. Lifesaving Equipment When a vessel founders in a remote location, the safety equipment carried must be capable of preserving the life of its crew in whatever environment the vessel may be operating, until help can arrive. The safety equipment carriage requirements for small fishing vessels, however, do not take into account vessels operating in remote regions in severe climatic conditions. The crew of a vessel that sinks rapidly may not have time to manually launch a liferaft before abandoning ship. As evidenced by the hanger found within the PFD coverall of the captain, the Avataq foundered quickly and the crew had little time to don survival equipment and manually launch the liferaft. A liferaft sitting in deep chocks or equipped with a suitable release mechanism such as a hydrostatic release is likely to deploy and be available to the crew in the water. During the subsequent extensive air search, neither the raft nor its canister were spotted in the debris field, suggesting that they likely sank with the vessel. Once the crew members found themselves in the water without a liferaft, their survival time was limited in part by the amount of thermal protection they were wearing. Full immersion suits are not comfortable to work in; consequently, most small vessel operators are more familiar with and tend to use PFD coveralls. The two victims whose bodies were recovered were wearing PFD coveralls, which provide protection against hypothermia for less time than a full immersion suit. In the best of circumstances, the response time of SAR resources to accidents in Arctic regions can be beyond the capabilities of PFD coveralls to keep a victim in the water from succumbing to hypothermia. Conversely, the carriage and the wearing of immersion suits significantly increases the crew's chance of surviving in the water until SAR resources arrive. Indeed, in the January 1993 sinking of the scallop dragger Cape Aspy off Nova Scotia, one crew member wearing an immersion suit was recovered from the frigid water approximately six hours after the vessel sank.(13) At present, there are no statutory requirements for lifesaving equipment such as liferafts, deep chock or hydrostatic releases, and immersion suits to be carried on board small fishing vessels such as the Avataq. Given that operating conditions vary from location to location across Canada, safety equipment carriage standards, appropriate for vessels operating in southern Canada, do not provide protection for the crews of vessels operating in the isolated Arctic marine transportation environment. Crew Training Although coastal seafaring is a traditional activity dating back thousands of years in the Canadian Arctic, the use of small fishing vessels carrying heavy cargoes on offshore voyages has engendered new hazards for northern seafarers. Special technical skills and knowledge are required to ensure safe and efficient vessel operations. Although such knowledge can be acquired on the job, formal courses and training, coupled with sea-going experience, provide an enhanced awareness of safe operational practices. Without the guidance derived from such training, the crew of the Avataq did not have the required knowledge of cargo loading, stability, and the deleterious effect of free surface water to recognize the risks associated with operating the vessel under conditions that could be expected to be encountered during the voyage. The lack of appropriate safety equipment on board the Avataq indicates that the crew might not have been aware of the potential consequences of an on-board emergency that would force them to rapidly abandon ship. MED training provides mariners with a better understanding of hazards associated with the marine environment and their vessel. This training provides crews with the knowledge of the type of safety equipment that should be carried and of the necessary coping skills for on-board emergencies such as abandoning ship into cold water. Without the knowledge acquired through formal MED training, the master and the crew of the Avataq might not have recognized the seriousness of their situation. The liferaft was likely not freed from its lashings before the vessel sank. Search and Rescue Nunavut, the Yukon Territory, and the Northwest Territories occupy a geographically large and isolated region. Gales are frequent during the short shipping season, and the seawater and air temperatures remain relatively cold. Survival time for persons in the water or in liferafts can be limited, requiring a prompt SAR response if lives are to be saved. A prompt SAR response, however, requires immediate notification of the appropriate RCC so that aircraft or vessels may be dispatched. The MCTS centres in Iqaluit and Thunder Bay act as ears for the RCCs, monitoring MF radio communications and listening for distress calls. The Avataq, however, was equipped with only a short-range CB radio and with an MF radio incapable of transmitting on 2182 kHz, the marine distress and calling frequency. As a result, when the Avataq began experiencing problems, which culminated in its foundering, the MCTS centres and RCC Trenton were unaware that it was in distress. An advantage of CB radio is its extensive use throughout the Arctic region as a means of inexpensive, short-range communications. Since many homes and vehicles in Arviat were equipped with CBs, the calls from the Avataq leading up to and at the time of the foundering were monitored by several members of the community. Rather than informing the local EMO officer, an ad hoc land-based search party was organized in an attempt to locate the vessel. As a result, Arviat EMO and NES Iqaluit officials were not notified for almost 1.5 hours. No procedures were in place to ensure that the appropriate RCC was notified. NES Iqaluit proceeded to assess whether the Avataq had indeed foundered and to identify local SAR resources. A telephone call was made to CCG MCTS Iqaluit seeking information on what vessels were in the vicinity of the occurrence. However, the nature of the emergency was not communicated to MCTS Iqaluit, which in turn did not inform RCC Trenton that the Avataq might have foundered. While local authorities may wish to react, an efficient SAR operation requires that the appropriate RCC be notified as soon as possible. Resources may then be dispatched expeditiously to the area. In this occurrence, although Arviat EMO was informed of the distress by area residents at 0255 and immediately called NES Iqaluit, NES Iqaluit did not inform RCC Trenton until 2.5 hours later. EPIRBs, which operate on 406 MHz, provide an immediate distress signal and have become common; however, the Avataq was not equipped with one and was not required to be so equipped. Had the vessel carried a float-free EPIRB or had the emergency been immediately communicated to NES Iqaluit, RCC Trenton would have become aware sooner of the vessel's sinking. Given earlier notice, the Hercules aircraft that was operating north of the area could have arrived on scene within the estimated survival time of those persons in the water who were wearing PFD coveralls. The heavy cargo load and the resulting low freeboard made the Avataq vulnerable to shipping water on deck as the weather deteriorated. The free surface effect of water shipped on the afterdeck and retained by the stopped-up scuppers probably reduced the vessel's already marginal transverse stability, causing the Avataq to heel, downflood, and sink. The involvement of RCC Trenton and the subsequent tasking of SAR resources were delayed while concerned local citizens conducted a land search and while NES Iqaluit assessed whether the Avataq had actually sunk. The Avataq was not equipped with an appropriate MF radio or a 406-MHz EPIRB with which to send distress signals, nor was it required to be so equipped. The Avataq was not equipped with an automatically releasing liferaft or immersion suits to increase the crew's probability of survival in cold water, nor was it required to be so equipped.Findings as to Causes and Contributing Factors The heavy cargo load and the resulting low freeboard made the Avataq vulnerable to shipping water on deck as the weather deteriorated. The free surface effect of water shipped on the afterdeck and retained by the stopped-up scuppers probably reduced the vessel's already marginal transverse stability, causing the Avataq to heel, downflood, and sink. The involvement of RCC Trenton and the subsequent tasking of SAR resources were delayed while concerned local citizens conducted a land search and while NES Iqaluit assessed whether the Avataq had actually sunk. The Avataq was not equipped with an appropriate MF radio or a 406-MHz EPIRB with which to send distress signals, nor was it required to be so equipped. The Avataq was not equipped with an automatically releasing liferaft or immersion suits to increase the crew's probability of survival in cold water, nor was it required to be so equipped. There was an awareness that the Avataq and other similar vessels were engaged in loading cargo at the Port of Churchill for delivery to communities on the western shore of Hudson Bay. Concerns for the safety of the vessels' practices had not been identified and passed on to the appropriate authorities. As a result, no assessment was made to determine whether the vessels were safely loaded or seaworthy for carrying cargo. Without the knowledge acquired by formal training or experience in cargo loading, stability, or free surface effect, the crew of the Avataq did not recognize the risks associated with operating the vessel in the conditions encountered during the voyage. Safety equipment carriage standards that are deemed to be appropriate for vessels operating in southern Canada are not adapted for the protection of crews of vessels operating in the isolated Arctic marine environment. The NES does not have clear procedures in place to ensure that the appropriate RCC is notified promptly in situations when SAR resources may be needed. Without the knowledge acquired by formal training in MED, northern operators of small commercial vessels may not have the ability to assess accurately their vessel's safety equipment carriage requirements or the skills necessary to safely abandon ship into cold water.Findings as to Risk There was an awareness that the Avataq and other similar vessels were engaged in loading cargo at the Port of Churchill for delivery to communities on the western shore of Hudson Bay. Concerns for the safety of the vessels' practices had not been identified and passed on to the appropriate authorities. As a result, no assessment was made to determine whether the vessels were safely loaded or seaworthy for carrying cargo. Without the knowledge acquired by formal training or experience in cargo loading, stability, or free surface effect, the crew of the Avataq did not recognize the risks associated with operating the vessel in the conditions encountered during the voyage. Safety equipment carriage standards that are deemed to be appropriate for vessels operating in southern Canada are not adapted for the protection of crews of vessels operating in the isolated Arctic marine environment. The NES does not have clear procedures in place to ensure that the appropriate RCC is notified promptly in situations when SAR resources may be needed. Without the knowledge acquired by formal training in MED, northern operators of small commercial vessels may not have the ability to assess accurately their vessel's safety equipment carriage requirements or the skills necessary to safely abandon ship into cold water. Safety Action Action Taken By TCMS After this occurrence, TCMS met with the Government of Nunavut and agreed to translate the Ship Registration Guide into Inuktitut. Amendments to the Life Saving Equipment Regulations came into force on 14 March 2002 and require all vessels under 25 m that are equipped with liferafts to have provision for the rafts to float free in the event of a sinking. TCMS has issued Ship Safety Bulletin (SSB) No. 03/2001 recommending that all vessels, irrespective of size, have float-free arrangements for liferafts. TCMS is also proposing amendments to the Life Saving Equipment Regulations to require that liferafts be stowed in readily accessible locations. In the interim, SSB No. 07/2001 has been issued reminding vessel owners of the importance of having lifesaving equipment visible and accessible. TCMS, with assistance from industry groups, is also examining certification and training requirements for small commercial and fishing vessels, with a goal of designing mandatory operator training and qualifications. Amendments to the Ship Station (Radio) Regulationsand the Ship Station (Radio) Technical Regulations are being phased in over the next few years. As of 01 April 2002, small commercial vessels more than 8 m long (which includes the Avataq) operating more than 20 miles from shore are required to carry an EPIRB. Since the occurrence, TCMS has reorganized the Prairie and Northern Region Branch and moved its headquarters to Winnipeg, Manitoba, from Ottawa. By CCG MCTS Central and Arctic Region With the support of Department of National Defence Search and Rescue New Initiatives funding for three years, MCTS Iqaluit implemented an Inuktitut language marine radio safety service during the 2001 operating season. The service is based in Iqaluit and provides coverage 20 hours per day, 7 days per week, during July, August, and September. Regularly scheduled broadcasts focus on weather and tide information, as well as hazards to navigation. Although the system is intended to cover the waters of Frobisher Bay, the coverage area in fact extends beyond and in other directions as well. A listening watch is also kept on the MF hunters' frequencies favoured by Inuit hunters and seafarers. Safety Concerns TC Marine Inspections The Board continues to be concerned that any shortcomings with the monitoring of small commercial vessels, particularly in remote areas, may result in vessels being used for carrying cargo beyond their capabilities. The Avataq had been operating as a cargo vessel for at least five years before this occurrence but was not inspected for this type of operation. As a result, neither the inspector nor the master had participated in an assessment of the capabilities of the vessel to carry cargo according to the applicable regulations. The determination of the appropriate operating parameters for this type of voyage was left to the knowledge and the experience of the crew. Because the master was uncertified, it would not be reasonable to expect that he possessed the competences required to determine whether he should have been operating the Avataq given the loaded condition and the area of operation. By not defining the operational parameters of the vessel and the capabilities of its crew through the certification process, a master's ability to assess risks is potentially compromised. The fact that he or she may not perceive the risk in time to take corrective action increases the probability and the adverse consequences of an accident. Emergency Response The investigation into the 1994 sinking of the pleasure craft Qasaoq in Frobisher Bay with the loss of 8 lives identified deficiencies with the timeliness of the Iqaluit EMO's notification of the occurrence to RCC Halifax (TSB Report No. M94H0002). Although the delay did not play a role in the outcome of the occurrence, it was identified as a deficiency that had potential to place lives at risk in the isolated Arctic environment. After this occurrence, personnel from key agencies(14) involved in the SAR operations in the Arctic and representatives of local authorities met to review mandates and to discuss procedures relating to SAR operations. It was agreed that RCC Trenton or RCC Halifax must be immediately notified of marine accidents. At the time of the Avataq occurrence, there was a delay of 2.5 hours before NES Iqaluit informed RCC Trenton of the occurrence. This delay held up the tasking of a SAR Hercules that was already in the area and reduced the efficacy of the SAR response. Given the continuing delays in notifying the appropriate RCC, the Board is concerned that the agreements made between the key agencies after the Qasaoq occurrence have not been effectively implemented, resulting is a continued risk to seafarers and others in peril in the area. The Board will continue to monitor and assess these types of occurrences with a view to determining the need for further safety action.